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M.O.T. Academy Registration

HomeM.O.T. Academy Registration

Registration Form

M.O.T. Academy Registration Form

M.O.T. Registration Pack

Personal Information
Authorized Pick Up & Previous School
Emergency Contacts
Release of Liability
Medical Information
Current Doctors
Financial Information
CC Authorization
Bank Authorization
Photo Waiver
Miscellaneous

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Date of Entry

STUDENTS PERSONAL INFORMATION

First Name *

Last Name *

Street Address *

City *

State *

Postal Code (ZIP) *

Birthdate (mm/dd/yyyy) *

Age

SSN *

MOTHER'S PERSONAL INFORMATION

Lives w student

Lives with the student

First Name

Last Name

Street Address

City

State

Postal Code (ZIP)

Mother's E-mail

SSN

Ocupation

Employer's Name& Phone

Years in Current Occupation

Phone Numbers

Phone

Add Remove

FATHER'S PERSONAL INFORMATION

lives w student

Lives with the student

First Name

Last Name

Street Address

City

State

Postal Code (ZIP)

Father's E-mail

SSN

Ocupation

Employer's Name& Phone

Years in Current Occupation

Phone Numbers

Phone

Add Remove

GUARDIAN'S PERSONAL INFORMATION

lives w student

Lives with the student

First Name

Last Name

Street Address

City

State

Postal Code (ZIP)

Guardian's E-mail

SSN

Ocupation

Employer's Name& Phone

Years in Current Occupation

Phone Numbers

Phone

Add Remove

Parent Status *

Married

Separated

Divorced

Widowed

Single

In case of divorce or separation, who has legal custody of child

Mother

Father

Guardian

Is there a restraining order or legal issue *

YES

NO

If yes, Please submit a copy of the appropriate legal document(s) regarding this court order

CANNOT PICK UP CHILD AT SCHOOL

Mother

Father

Signature *

Clear

M.O.T. Academy

www.motacademy.com

info@motacademy.com

14202 SW 62nd Street

Miami, Florida, 33183

(786) 299-5915